Age to start HIV therapy in children needs research
Large randomised controlled trials to determine when to initiate
treatment with antiretroviral therapy in children with HIV are urgently
needed,
according to two consultant paediatricians who debate the
issue in the online, open access journal PLoS Medicine.
Steven Welch, consultant in paediatric HIV and infectious diseases at
Heartlands Hospital in Birmingham, argues that treatment should be deferred.
However, Di Gibb, professor in epidemiology and a consultant paediatrician
at the Medical Research Council Clinical Trials Unit, London, lays the
case for treatment to be initiated earlier.
Both experts agree that in infants less than one year old high susceptibility
to life-threatening opportunistic infections and irreversible brain damage
from HIV encephalopathy during such a critical period of development
means
that early initiation of antiretroviral therapy (ART) is warranted.
However, Dr Welch argues that, for children older than one year, treatment
should be delayed until it is really needed. He highlights results from
the SMART trial in adults, which indicate that treatment interruption
increases risk of opportunistic disease or death, and emphasises that
the only way of minimising exposure, and hence cumulative adverse effects,
is to avoid starting treatment too early.
Dr Welch also points out that a lack of palatable paediatric formulations
and problems related to families not disclosing their child’s diagnosis
to friends and schools creates a risk of learned poor drug adherence
practices and possible limitation of future treatment options because
of drug resistance.
Professor Gibb counters that the lack of paediatric formulations should,
rather than defer ART, spur lobbying of pharmaceutical companies to make
more appropriate formulations. She argues that delaying treatment is
no longer an option and that early initiation of ART for children is
more important than for adults because in children HIV disease progression
is faster, significant immune recovery is better, bacterial infections
are more common and serious, occur at high CD4 counts and are reduced
by ART, better growth occurs if ART is started earlier and, finally,
HIV encephalopathy is particularly dangerous for children exposed to
HIV during brain development.
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